Patient personality dimensions and transference patterns: An empirical investigation

Introduction: Since Freud (1912, 1917) first recognized that patients displace intense feelings and conflicts associated with a significant figure of childhood onto the analyst, actualizing in therapy their dysfunctional patterns of relatedness, the concept of transference has revised radically. Beyond the theoretical divergences, as well as the technical controversies related to the use of transference interventions across various treatment (Bateman, Fonagy, & Gabbard, 2007; Gelso & Bhatia, 2012; Gilbert & Leahy, 2007; Høglend, 2014; Yeomans, Clarkin, & Kernberg, 2015), in the contemporary terms, it refers to a patient’s patterns of feeling, thought, perception, motivation, and behavior that emerge within the therapeutic relationship, and reflects enduring aspects of the patient’s personality functioning (Westen & Gabbard, 2002). Clinicians of all theoretical orientations should pay particular attention to these ubiquitous phenomena that provide valuable information on patients’ core psychological dynamics (Gabbard, 2014; Høglend, 2014; Kernberg, 1984; Lingiardi & McWilliams, 2017; McWilliams, 2011). To date, only a few empirical investigations have examined the relationship between transference patterns and patients’ personality pathology. Overall, research findings indicated that patients with Cluster A and B personality disorders, compared to Cluster C patients, tend to enact more dysfunctional and difficult to manage relational patterns in therapy; moreover, among Cluster B, borderline patients showed mixed and intense transference responses in therapy (e.g., Bradley, Heim, & Westen, 2005; Bourke & Grenyer, 2010; Colli, Tanzilli, Gualco, & Lingiardi, 2016; Drapeau & Perry, 2009; Drapeau, Perry, & Koerner, 2010; Ruiz, Pincus, & Bedics, 1999; Stern, Herron, Primavera, & Kakuma, 1997). However, no research has considered the associations with personality dimensions or traits. The present study attempted to bridge this gap using a dimensional diagnostic approach based on a multifaceted model of personality syndromes: the SWAP Personality Dimension Scales (Shedler & Westen, 2004). These personality dimensions showed psychometrically robust characteristics and clinical sensitivity to capture the complexity of personality pathology (see Westen & Muderrisoglu, 2006). Method: A national sample of clinicians of different theoretical orientations (N=90) completed the Psychotherapy Relationship Questionnaire (PRQ; Bradley et al., 2005; Westen, 2000) to identify transference patterns, and the Shedler-Westen Assessment Procedure-200 (SWAP-200; Shedler & Westen, 2004; Shedler, Westen, & Lingiardi, 2014) to assess personality dimensions regarding a patient currently in their care. Notably, in this study we used (a) the empirically supported PRQ version (Tanzilli, Colli, Gualco, & Lingiardi, 2018), that consists of six transference dimensions characterized by excellent internal consistency (Streiner, 2003): hostile (α=.93), positive/working alliance (α=.88), special/entitled (α=.84), anxious/preoccupied (α=.82), avoidant/dismissing attachment (α=.81), and sexualized (α=.88); and (b) the twelve SWAP Personality Dimension Scales identified by Shedler and Westen (2004) performing a factor analysis to all the SWAP-200 items: psychological health; psychopathy; hostility; narcissism; emotional dysregulation; dysphoria; schizoid orientation; obsessionality; thought disorder (or schizotipy); oedipal conflict (or histrionic sexualization); dissociation; and sexual conflict. Results: Bivariate correlations showed that distinct SWAP personality dimension scales were significantly associated with specific transference patterns. Notably, the SWAP hostility and psychopathy were positively related to hostile transference, while the SWAP narcissism correlated with special/entitled pattern. Positive/working alliance pattern was negatively related to the SWAP schizoid orientation, while the SWAP dysphoria correlated positively with anxious/ preoccupied transference. Avoidant/dismissing attachment pattern was negatively and strongly related to the SWAP emotional dysregulation, and positively associated with both SWAP schizoid orientation and narcissism. Finally, sexualized transference was related to the SWAP sexual conflict. Conclusions: These results showed that transference patterns are coherently and meaningfully related to patients’ personality features, confirming the diagnostic value of these clinical phenomena as an essential tool in understanding personality traits/dimensions that underlie the patients’ pathology. The implications for clinical practice are apparent given that these findings inform clinicians of all theoretical approaches about the interpersonal patterns that can be activated by their patients during psychotherapy, providing a roadmap for effective therapeutic intervention and decision making.. Moreover, this study supports the potential strengths of the PRQ’s use in both empirical and clinical contexts. References Bradley, R., Heim, A. K., & Westen, D. (2005). Transference patterns in the psychotherapy of personality disorders: Empirical investigation. The British Journal of Psychiatry, 186, 342–349. doi:10.1192/bjp.186.4.342 Høglend, P. (2014). Exploration of the patient–therapist relationship in psychotherapy. The American Journal of Psychiatry, 171, 1056–1066. doi:10.1176/appi.ajp.2014.14010121 Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic Diagnostic Manual, 2nd ed. (PDM-2). New York, NY: Guilford Press. Tanzilli, A., Colli, A., Gualco, I., & Lingiardi, V. (2018). Patient personality and relational patterns in psychotherapy: Factor structure, reliability, and validity of the Psychotherapy Relationship Questionnaire. Journal of Personality Assessment, 100(1), 96-106. doi:10.1080/00223891.2016.1272050 Tanzilli, A., Lingiardi, V., & Hilsenroth, M. (2018). Patient SWAP-200 Personality Dimensions and FFM Traits: Do They Predict Therapist Responses?. Personality Disorders: Theory, Research, and Treatment, 9(3), 250–262. doi:10.1037/per0000260